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Global Antibiotic Resistance Partnership (GARP)–India Inaugural Meeting August 25–26, 2009, New Delhi The GARP-India Inaugural Meeting was held in New Delhi’s India Habitat Centre on August 25-26, 2009.

It brought together about thirty experts in medicine, biology, and the social sciences to confer on the vexing problem of antibiotic resistance. The meeting was led by Dr. N.K. Ganguly, Chairman of the GARPIndia National Working Group. Professor Ganguly is the president of JIPMER (Jawaharlal Institute of Postgraduate Medical Education & Research) in Puducherry, distinguished biotechnology professor and advisor at the Translational Health Science and Technology Institute of the National Institute of Immunology, and a former director general of the Indian Council of Medical Research.

GARP, funded by the Bill and Melinda Gates Foundation, is an initiative of the Center for Disease Dynamics, Economics & Policy at Resources for the Future in Washington, DC. The goal of GARP is to develop strategies to delay the spread of antibiotic resistance—including strategies to reduce the need for antibiotics— in five low- and middle-income countries (India, Kenya, South Africa, Vietnam, and China). The project website (www.resistancestrategies.org) provides more detail on the overall plan and tracks recent events.

Several themes featured prominently in formal presentations and group discussions throughout the meeting: Resistance of common bacteria to widely used antibiotics is prevalent in India. In a recent World Health Organization (WHO) pilot study, antimicrobial resistance (AMR) was tracked for two years at large urban hospitals in New Delhi, Vellore, and Mumbai. AMR rates were high (at least 40 percent for most) for all major classes of these drugs, with particularly high rates and rapid increases for fluoroquinolones. Studies in other Indian hospitals have produced findings compatible with this surveillance data, though many represent small numbers of bacterial isolates, short study lengths and a limited population base.

The general public lacks information on how and when to use antibiotics. In a study done by the Delhi Society for Promotion of Rational Use of Drugs (DSPRUD), only 26 percent of people in rural areas knew about antibiotics, and only 35 percent of consumers who were given a prescription for antibiotics reported that they took the full course.

Current regulation and enforcement mechanisms do not prevent over-the-counter purchases of antibiotics. A DSPRUD study of pharmacies in Delhi found that one-third of people who bought antibiotics did so without a prescription, despite laws requiring one. These instances include both self-prescribing and pharmacist prescribing. Others report that antibiotics can be purchased at general shops without pharmacists or any other individuals trained in drug use. Compared to when antibiotics are purchased with a prescription, the duration of treatment appears to be shorter when they are purchased without one or on the advice of a pharmacist. The DSPRUD study found that the most common antibiotics purchased without a prescription were fluoroquinolones, while cephalosporins were the most common antibiotic purchased with a prescription. Additionally, the WHO study mentioned above

found that private hospitals prescribe fluoroquinolones and expensive antibiotics more than public hospitals. These differences bear investigation for the appropriate use of antibiotics.

Microbiology services to test for antibiotic resistant infections are suboptimal. Most hospitals are far from emulating the speed and accuracy of microbiology departments in elite hospitals. In some cases, public-private partnerships can help hospitals acquire timely data. However, microbiological testing and surveillance is improving in New Delhi as hospitals push to receive accreditation. As in other countries, antibiotic resistance testing that is widely used and relied upon for clinical decisionmaking may require what amounts to a culture change in hospitals.

Infection control in hospitals varies but needs improvement in most. Some private hospitals have introduced infection control nurses who monitor the environment for general cleanliness, hand-washing, care related to catheters, isolation of infectious patients, and appropriate use of antibiotics.

A WHO pilot study demonstrated the feasibility of maintaining AMR surveillance at a relatively low cost with high quality. Low- and middle-income countries have had a difficult time setting up and maintaining AMR surveillance. This study, which had three surveillance sites in India, used E. coli as an indicator organism for drug resistance trends. Resistance testing was done in large hospitals, and antibiotic use was monitored both by interviewing patients as they exited pharmacies and using bulk purchase data from pharmacies. India could benefit from a sustainable surveillance system to monitor antibiotic resistance and use, but important issues remain, such as the selection of surveillance sites; who should run, fund, and monitor the system; and which organisms should be tested. Ideally, surveillance would cover not just hospitals, but also levels of resistance in the community.

Tackling this problem will require participation from all relevant sectors. The absence of veterinary representatives was noted, and the importance of including them in the future was emphasized. Resistance is already being recognized as a serious problem in hospital and community settings, but broadly representative data on resistance rates, antibiotic use, and the efficacy of different interventions needs to be generated. It is a definite advantage that a problem has been identified, but the details will determine the best interventions to curb resistance.

Next Steps Among the first steps is appointment of the full National Working Group (NWG) for GARP-India, representing all relevant stakeholders and sectors. Professor Ganguly chairs the NWG, which will guide the subsequent research.

A “situation analysis� is in preparation using information presented at the meeting as well as additional background material. This document will assess the current status of antibiotic resistance in India and the factors that drive it. It will be used to develop a strategy for sustainable interventions to manage antibiotic resistance in India. In the meantime, research proposals emerging from the inaugural meeting will be followed up. Choosing the best solutions will require analysis of local situations and examining what has worked for other public health problems. GARP is also developing mathematical models, to be used in a variety of countries, which will be available as decision tools for making these choices.

Avenues for slowing the spread of antibiotic use that were raised at the meeting include: improving regulation of antibiotic sales (for example, by enforcing prescription laws), encouraging pharmaceutical investment, improving hygiene in hospitals and food production, and increasing the use of new vaccines.

Some of these solutions will be most relevant in large urban hospitals, whereas others will be better

suited to remote areas. Recent experience in the global management of HIV, malaria, and tuberculosis has demonstrated that norms can change and be adopted on a broad scale. These include moving away from syndromic treatment and the adoption of combination treatments.

Another priority will be to quantify the economic and health burden of antibiotic resistance, contributing to the development of a methodology for burden estimation that will be applicable globally. Characterizing the burden will allow researchers to estimate the benefits interventions could have on health in India.

A final report from GARP-India, incorporating the policy discussions and decisions in India, will be folded into a five-country GARP report. A collaborative meeting, involving all five GARP countries and countries not yet included, will focus on this global report. It is anticipated that GARP will remain active in the long term, with new phases following this initial work.

For more information on this initiative, please contact: NEW DELHI Alice Easton GARP-India country coordinator Email: easton@rff.org Mobile: +91 9971066145

Conference Participants: Dr. Narendra K. Arora Dr. Preena Bhalla Dr. Kaushik Bharati Dr., Sujith J. Chandy Ms. Alice Easton Dr. Nirmal K. Ganguly Ms. Hellen Gelband Dr. Patricia Geli Dr. Usha Gupta Dr. M. Jawahar Dr. Sadhna Joglekar Dr. K. R. John Dr. P. C. Joshi Dr. Ambujam Nair Kapoor Dr. Ramanan Laxminarayan Dr. Renuka Munshi Dr. Ramesh S. Paranjape Dr. NS Prashanth Dr. Dasarathy Raghunath Dr. Ashok Rattan Dr. Ashok J. Tamhankar Dr. Kurien Thomas Dr. Neena Valecha Ms. Aditi Vasan Dr. Chand Wattal

WASHINGTON, D.C. Hellen Gelband Program Fellow Email: gelband@rff.org

Some of the delegates present at the GARP-India meeting, representing a range of fields.

Dr. NK Ganguly (right) chaired the meeting. Dr. Laxminarayan (left) is the principal investigator of the GARP project from Resources for the Future.